TAKING VIRUSES TO HEART: AN INTERESTING CASE OF COXSACKIE MYOCARDITIS

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Diagnosing the cause of heart failure in young, healthy adults can be challenging and often associated with high morbidity. Here, we present a case of heart failure associated with viral myocarditis in a patient with a bicuspid aortic valve. CASE PRESENTATION: A 28-year-old man with no medical history presented with epigastric pain, nausea, vomiting, chest pain, and chills. On initial evaluation, he was afebrile, with a blood pressure of 102/72 mmHg, and a heart rate of 127 bpm. A 2/6 mid-systolic murmur and 2/6 early diastolic murmur were heard without jugular venous distension. Otherwise, his exam was unrevealing. Labs were significant for elevated liver function tests (AST 372 U/L and ALT 422 U/L), elevated creatinine of 1.64 mg/dL (no baseline available), and an elevated white blood cell count of 14.7 K/uL. Abdominal computed topography was unremarkable. A transthoracic echocardiogram showed a dilated left ventricle with moderate to severe global hypokinesis with an ejection fraction of 30%. A large 2.8 cm x 1.0 cm mass on the aortic valve was seen causing aortic stenosis and moderate to severe aortic regurgitation, concerning for endocarditis. The patient was empirically initiated on gentamicin and vancomycin but clinically deteriorated into presumptively septic shock requiring supplemental oxygen, vasopressors, and continuous renal replacement therapy for renal failure. He was taken to the operating room for emergent resection and replacement of the aortic valve. However, intraoperatively the surgeon found and removed a heavily calcified bicuspid aortic valve. His blood cultures and microbiology of his valve revealed no infectious organisms; antibiotics were discontinued. Slowly he improved clinically. Without clear reason for his decompensation, a viral panel was obtained and returned positive for coxsackie B virus. DISCUSSION: In the United States, myocarditis is uncommon, impacting only one percent of the population. The Coxsackie viruses are the most common cause of infectious myocarditis, and predominantly affect men with the average age of onset being 42 years old. The cardiac manifestations of the virus typically occur two weeks after viral infection and are caused by direct cytopathic effects, pathologic immune responses, or autoimmunity triggered by the infection. Therapy with ribavirin has shown to reduce mortality in rodent models if initiated soon after inoculation which limits its applicability in human treatment. In this patient, his viral illness precipitated his acute clinical condition in the setting of a congenital bicuspid aortic valve with calcification, and he was treated with supportive therapy. CONCLUSIONS: This case highlights the importance of evaluating for viral myocarditis in young patients with acute heart failure and nonspecific symptoms and the need to remain vigilant for undiagnosed structural heart defects in otherwise healthy patients. Reference #1: Tam, Patricia E. "Coxsackievirus myocarditis: interplay between virus and host in the pathogenesis of heart disease.” Viral immunology 19.2 (2006): 133-146. Reference #2: O.V. Blagova, O.V. Blagova, A.V. Nedostup, E.A. Kogan, V.P. Sedov, Y.U.V. Frolova, S.L. Dzemeshkevich, A.G. Kupryanova, V.A. Zaidenov, A.E. Donnikov; High prevalence of viral and immune myocarditis in patients with "idiopathic” and genetic dilated cardiomyopathy: biopsy proved diagnosis, European Heart Journal, Volume 34, Issue suppl_1, 1 August 2013, P4238, https://doi.org/10.1093/eurheartj/eht309.P4238 DISCLOSURES: No relevant relationships by Kara Calhoun, source=Web Response No relevant relationships by Jennifer Duke, source=Web Response No relevant relationships by Brandy McKelvy, source=Web Response No relevant relationships by Abin Puravath, source=Web Response